1286

Abstract

Introduction: A 68 year-old man with chronic alcohol abuse and recent COPD exacerbation was admitted to our surgical ICU after a laparotomy for a small bowel obstruction. He was started on a lorazepam revised Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar) scale to help in the assessment and management of alcohol withdrawal syndrome (AWS). His post-operative course was complicated by respiratory distress requiring intubation. On hospital day 5, he was switched from lorazepam to PO vodka for AWS prevention due to a concern that lorazepam was causing oversedation, resulting in difficulty weaning from the ventilator. After a 24-hour trial of oral vodka was conducted, at 30ml every 6 hours, the patient was switched back to lorazepam due to escalating AWS. This medical case led to significant discussion among the medical teams involved regarding patient selection, indications, and evidence for this age-old, but controversial, therapy. Hospitalized patients with histories of chronic alcohol abuse risk developing AWS during their hospital course, and often require care in the ICU due to potentially lethal complications, such as seizures and delirium. Clinically, AWS is commonly defined as alcohol withdrawal symptom severity resulting in a CIWA-Ar score of greater than 20. Current first-line prophylaxis of AWS in SICU patients is intravenous (IV) benzodiazepines. CIWA-Ar score is evaluated every hour until a score of less than 10 has been maintained for at least 24 hours. If the CIWA-Ar score rises above 20, treatment should be initiated with higher doses of benzodiazepines. Historically ethanol has been used as an alternative for preventing AWS, particularly in surgical patients, but current literature on its use is lacking. Available research addresses IV ethanol for AWS prevention, and advises against its use because of the high cost, narrow therapeutic index, and unpredictable pharmacokinetics. Compared to benzodiazepines, oral (PO) ethanol may cause less sedation and respiratory depression at effective doses. Pharmacy cost-containment strategies may favor PO over more costly IV ethanol formulations. Despite its long-standing, therapeutic considerations, current literature is heavy weighted against the use of PO ethanol for AWS prevention, primarily due to the paucity of data validating its use. Nonetheless, many hospitals nationwide have PO ethanol available for patients with histories of alcohol abuse. At our institution, the Medication Safety and Quality Committee recently approved the use of PO ethanol for AWS prevention in surgical patients undergoing thoracic and head and neck procedures, given the high prevalence of alcohol abuse in these cohorts. Available literature suggests that use of PO ethanol is most effective when administered using a protocol, but a validated protocol has yet to be published. Our pharmacy recommends the use of 40% vodka in 30 mL doses (13g of ethanol) every 4 to 8 hours, with a starting dose of 0.5-1g/kg/day. The vodka is purchased by the pharmacy's supplier, stored in the pharmacy, and administered as a nonformulary drug. Due to potential drug interactions, additional precautions must be taken when using PO ethanol, including discontinuation of NSAIDs and/or the addition of GI prophylaxis, limitation of acetaminophen doses to under 2g/day, and the discontinuation of drugs that may cause a disulfiram-like reaction, such as metronidazole. In addition to logistical issues with its administration, many physicians ethically object to prescribing ethanol to patients who are addicted to alcohol. More research is needed regarding which patients may benefit from PO ethanol over standard first-line benzodiazepine therapy, and how to safely and effectively administer ethanol to these patients.